When addressing the needs of a client with a newly diagnosed spinal cord injury, the nurse understands that which of the following are true about nutritional needs?
The client will be NPO until fitted for a halo vest
A high calorie, high protein diet will be started within 3 days
High fiber and decreased protein is needed immediately after injury
Low fiber and no protein is needed 2 days after the injury
The Correct Answer is B
Choice A Rationale: Keeping the client NPO until fitted for a halo vest is not a standard practice, and nutritional support should be initiated as soon as possible.
Choice B Rationale: A high-calorie, high-protein diet is typically started within 3 days of a spinal cord injury to support healing and prevent muscle wasting.
Choice C Rationale: High fiber and decreased protein are not the immediate dietary needs after a spinal cord injury. High protein intake is important for tissue repair.
Choice D Rationale: Low fiber and no protein would not be recommended 2 days after a spinal cord injury, as protein intake is crucial for healing and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is A
Explanation
Choice A Rationale: A person who makes up stories when he is unable to remember actual events is confabulating. This can be seen as a way of filling in the blanks in their memory with plausible details that may or may not have happened. For example, a person with dementia may confabulate that they had lunch with a friend yesterday, when in fact they did not see anyone.
Choice B Rationale: reminiscing about the past, which is a normal and healthy way of recalling one's life experiences and sharing them with others.
Choice C Rationale: displaying compulsive and ritualistic behaviors, which are repetitive actions that a person feels compelled to perform, often as a way of reducing anxiety or distress.
Choice D Rationale: refusing to leave home to see a provider, which is a sign of agoraphobia, a fear of being in situations where escape might be difficult or embarrassing.
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